With a breast cancer diagnosis the challenge is not lack of information, but rather sorting through it all to determine what is important and relevant to you. Start here for a simplified overview that will orient you as you learn the specifics of your diagnosis.
Breast cancer is a disease of abnormal cell growth in the internal ducts or lobules – the part of the breast that produces and transports milk during lactation and breastfeeding. When abnormally growing cells accumulate within this network, they are called ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). DCIS and LCIS are considered non-life-threatening (benign) precursors to cancer.
If left untreated, abnormal cells may continue to divide uncontrollably, eventually forming a malignant tumor that grows into surrounding breast tissue. This is called invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC). Both are considered life-threatening cancer that is potentially curable. The majority of breast cancers are IDC (~70%) or ILC (~10%), followed by an aggressively invasive subtype of IDC called inflammatory breast cancer (IBC; <5%).
As tumors form and grow, they invade surrounding blood and lymph vessels, which serve as “highways” for cancer cells to travel (metastasize) to other locations in the body. We now know that metastasis happens quite early in the process of tumor development. Fortunately, the immune system usually destroys these wandering cancer cells. However, if cancer cells manage to escape detection by the immune system, they can give rise to new (secondary) tumors in other organs, e.g. liver, lungs, bone, brain, gut, etc. Cancer that has spread from the breast to other organs is called metastatic breast cancer, and while it is considered incurable, it can be treated with potentially life-extending therapies.
Additional Resources & Detail:
For a comprehensive and detailed explanation of how breast cancer develops, the different types of breast cancer, and much more, this is an outstanding online resource:
(And What about a Second Opinion?)
Multiple tests are used to diagnose breast cancer. Imaging studies are conducted to determine if cancer is present in the breast and if so, whether it is also present in other organs (metastatic). Imaging tests may include diagnostic mammography, ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and bone scintigraphy (bone scan).
When imaging studies detect area(s) of suspicious growth, the next diagnostic test is biopsy – the removal of suspicious cells for further analysis. This entails either a fine-needle aspiration cytology, in which cells are collected with a small needle (similar to that used for drawing blood), or a core needle biopsy, in which a small piece of tissue is removed. Biopsy samples are analyzed in the pathology laboratory to determine if the suspicious cells are benign (normal) or abnormal (cancer).
If abnormal cells are present in the biopsy sample, molecular analysis determines whether the cancer cells have certain known proteins that cause them to grow uncontrollably. These proteins include estrogen receptors (ER), progesterone receptors (PR), and human epidermal growth factor (HER2) receptors. Breast cancer may have any combination of these receptors (e.g., ER/PR positive but HER2 negative, or ER/PR negative but HER2 positive), or even none at all, which is referred to as “triple negative” breast cancer. ER/PR/HER2 status is evaluated because there are drugs that can be used to block these receptors in order to interfere with cancer cell growth. Additional molecular analysis can include evaluation for known genetic mutations (e.g. BRCA1/2) and other biomarkers (e.g. Oncotype DX) that medical providers use in diagnosis and treatment plan design.
Tumor location and size are used to determine the "stage" of the cancer. DCIS and LCIS are classified as stage 0 (precancerous). IDC, ILC, and IBC can be classified as stage I, II, III, or IV according to the size of the tumor in the breast, the presence or absence of tumor cells in lymph nodes surrounding the breast, and whether the tumor cells have spread (metastasized) from the breast to other organs of the body. Higher stage numbers mean that the cancer is more advanced (i.e., larger and/or growing more aggressively).
Additional Resources & Detail:
For a comprehensive and detailed explanation of tests used to diagnose and stage breast cancer, these are outstanding online resources:
What About a Second Opinion?
When you receive a breast cancer diagnosis, fear can make it feel like an emergency, especially when it is classified as a higher stage. While a breast cancer diagnosis is serious and potentially life-threatening, there is virtually always a window of opportunity to seek a second opinion before making a treatment decision. Having a second opinion can help you feel confident that your diagnosis is correct and that your treatment options have been thoroughly considered.
If resources permit, it is a good idea to be seen at a National Cancer Institute-Designated cancer center. Cancer centers receive NCI designation based on their cutting edge research and therapies, including treatment options, usually in the form of clinical trials, that may not be available elsewhere.
NCI-Designated cancer centers can be located here.
Information on getting a second opinion can be found here.
Keep reading for information on clinical trials in the section below.
(And What about Clinical Trials?)
The goal of cancer treatment is to eliminate as many cancer cells as possible. Surgery (lumpectomy or mastectomy) and radiation therapy are designed to remove the tumor and any remaining cancer cells in the breast. Surgery may also include removal of axillary lymph nodes (located near the armpit) which usually accumulate cancer cells as they leave the breast.
Thereafter, a variety of systemic treatments (drugs delivered throughout the body via the bloodstream) may be used in order to remove cancer cells that have spread beyond the breast and axillary lymph nodes. This includes chemotherapy (which prevents cancer cell growth); endocrine therapy (which blocks hormone receptors); HER2 therapy (which blocks HER2 receptors); and biological therapies including immunotherapy, which target specific molecular pathways that cancer cells use to survive and grow. Depending on the drug, systemic therapies may be given intravenously (infusion), by injection, or orally (pill).
The order of treatments can differ among treatment plans. When systemic therapy such as chemotherapy is administered prior to surgery this is called neo-adjuvant treatment. Benefits of neo-adjuvant treatment include being able to monitor therapeutic response (i.e., whether the tumor is shrinking) and reducing tumor size for safer surgical removal (e.g. when surgery poses risk of nerve or other tissue damage). When systemic therapy is administered after surgery this is called adjuvant treatment.
Additional Resources & Detail: :
For more detailed information on cancer treatments, this is an wonderful online resource from Breastcancer.org.
What About Clinical Trials?
Depending on your diagnosis, another treatment option is to participate in a clinical trial. Clinical trials are the means by which new cancer drugs are rigorously evaluated prior to FDA approval. Breast cancer clinical trials are randomized in design, meaning that participants and researchers do not choose who receives the experimental drug vs. placebo, which is done to prevent bias. A common misconception is that participating in a clinical trial may lead to compromised medical care. Indeed, the opposite occurs. Everyone enrolled in a cancer clinical trial receives “standard of care” treatment, meaning it meets or exceeds current clinical guidelines. Participants then also receive either the new drug(s) being tested or the placebo (in addition to the standard of care). All clinical trial participants are closely monitored during the study for both benefits and side effects. In short, clinical trials are a great option for those who want the prospect of receiving the next generation of cancer therapies before they otherwise become available.
For more detailed information on clinical trials this is an outstanding online resource at Breastcancer.org
To search for clinical trials for which you may be eligible -
How do I begin to manage my emotions?
A cancer diagnosis for you or someone you love can feel terrifying. The sheer volume of information coming at you can be challenging to navigate, especially alongside the emotional upheaval that a diagnosis brings. Post-treatment, the terrain can continue to feel dark and bumpy, with anxiety obscuring the way forward.
For emotional support there are many options, including support groups, therapy, and coaching. The similarity of these services is that they all use conversation to help you work through your feelings and problems in the company of those who “get it".
The main difference amongst these services is who provides them and how the sessions are structured. A support group is a gathering of people drawn together via similar issues to talk about what's troubling them. Support groups may be peer-led or led by a mental health professional, such as a social worker, counselor, or therapist. For individual support, the options are therapy or coaching. Therapists assess, diagnose, and treat various forms of emotional disturbance and distress. The focus of therapy is usually on the past in order to help you understand why you do what you do, including your emotional triggers and reactions. Clients typically participate in therapy for extended periods of time (e.g. years).
Coaching is similar to therapy by providing a safe, non-judgmental space in which to experience and process your emotions. In fact, emotional relief can be a goal in a given coaching session. Coaching differs from therapy in that it is focused on the present, with future orientation, and tends to be a much shorter process. Coaches use a question-based process that prompts you to clarify your goals (your “what”), their importance (your "why"), and a plan for reaching them (your “how”). With coaching, you will learn techniques that you can continue to use on your own, which empowers you to respond more creatively to any situation or circumstance, whether it is during your cancer experience or your life beyond.
Additional Resources & Detail:
Virtual Support Groups:
Metavivor’s peer-to-peer support groups are offered across the US and are dedicated specifically to persons experiencing metastatic (stage IV) disease.
Visit the Resources Page for some things you can try on your own.
And if you'd like to explore personalized coaching you can connect with me here.